Qualifying Events (QEs) and HIPAA Special Enrollment Rights (SERs) are the situations that allow employees and dependents to make changes to their employer-sponsored benefits outside the annual Open Enrollment period – or, in some cases, to continue coverage after losing eligibility.
These rules matter because, under IRS Cafeteria Plan regulations for Premium Only Plans (POPs) and FSAs, most benefit elections must remain locked in for the entire plan year when premiums are paid pre-tax. QEs and SERs create the limited exceptions that allow midyear election changes.
They also matter because certain QEs result in a loss of eligibility, which can trigger rights under federal COBRA or applicable state continuation laws.
At the same time, HIPAA Special Enrollment Rights allow an active, still-eligible employee (and family members) to enroll or make plan changes midyear when specific life events occur.
This page summarizes the three major categories employers must understand, with deeper information available on their dedicated WB Compliance Wiki pages:
- IRS Section 125 Qualifying Events – midyear changes to pre-tax elections
- HIPAA Special Enrollment Rights – federally required enrollment or plan-change opportunities while still eligible
- COBRA Qualifying Events – loss-of-eligibility events that trigger continuation coverage rights
IRS Section 125 Qualifying Events
Under a Section 125 Cafeteria Plan (POP and/or FSA), most benefit elections must remain in place for the full plan year. QEs allow employees to make midyear changes to their pre-tax elections, and most employers mirror these same rules for post-tax contributions for administrative consistency.
Changes in Legal Status
These events generally allow employees to add, drop, or change coverage for themselves and/or dependents:
- Marriage
- Divorce
- Legal separation or annulment
- Birth, adoption, or placement for adoption (note: pregnancy itself is not a QE)
- Death of an enrolled family member (when eligibility is affected)
Changes in Employment Status
These events affect the employee’s own eligibility:
- Starting or ending employment
- Moving from full-time → part-time (or vice versa) when eligibility changes
- Returning from a leave of absence (LOA) when eligibility changes
- Moving into or out of a benefit-eligible job classification
LOA Note
Eligibility during leave depends on:
- The employer’s written LOA policy
- Applicable federal/state leave laws (FMLA, CFRA, PDL, etc.)
- The employer’s ERISA wrap or plan document
- Carrier or plan rules
Because LOA issues are primarily employment law matters, employers should consult legal counsel for determining eligibility and compliance. Brokers should tread lightly here and review their E&O before advising.
Changes in Dependent Eligibility
- Dependent reaches the plan’s limiting age (e.g., turning age 26)
- This also triggers a SEP on the individual Exchange
- And this is a COBRA Qualifying Event if applicable
- Dependent becomes newly eligible due to plan or policy updates
Other Common Section 125 Permitted Events
- Significant cost changes outside Open Enrollment (due to employer or carrier action)
- Significant coverage changes outside Open Enrollment
- New benefit options introduced midyear
- Loss or gain of other group coverage
- Judgments, decrees, or orders (e.g., Qualified Medical Child Support Orders – QMCSOs)
HIPAA Special Enrollment Rights (SERs)
HIPAA SERs are federally required rights that allow employees and dependents to enroll in or change group health plan coverage midyear when certain life events occur. These apply only when a person is still eligible for the employer’s plan.
Some employers casually call these “HIPAA QEs,” but legally they are Special Enrollment Rights – separate from Section 125 QEs and COBRA QEs.
Think of HIPAA as the safety net that preserves continuity of coverage when major life circumstances change.
For detailed rules, examples, and timing requirements, see the HIPAA Special Enrollment Rights page in our WB Compliance Wiki.
- Loss of Other Coverage
- This SER allows enrollment in another available employer plan or an individual/family plan on a state Exchange.
- Loss includes:
- Employer-sponsored group coverage
- Individual/Marketplace coverage
- Medicaid or CHIP
- Coverage lost due to divorce, separation, or death
- Employer ceasing contributions on another plan
- Exhaustion of COBRA (Voluntarily dropping COBRA early does not count.)
- Loss includes:
- A HIPAA SER that is a loss of coverage allows enrollment in any available employer plan for which they are eligible, or to enroll in an Individual & Family Plan through their state Exchange.
- This SER allows enrollment in another available employer plan or an individual/family plan on a state Exchange.
- Gaining a New Dependent
- These SERs allow employees to add the new dependent and/or change their own plan elections, even if they previously waived coverage.
- Marriage
- Birth (coverage must be available retroactively to date of birth)
- Adoption or placement for adoption (retroactive to date of placement)
- These SERs allow employees to add the new dependent and/or change their own plan elections, even if they previously waived coverage.
- Medicaid/CHIP Eligibility Changes
- A HIPAA SER applies when an employee or dependent:
- Becomes newly eligible for premium assistance, or
- Loses Medicaid/CHIP eligibility
- This category uses a 60-day enrollment window (longer than most SERs).
- A HIPAA SER applies when an employee or dependent:
- Loss of Coverage Due to Moving Out of a Plan’s Service Area
- Common with HMOs and regional networks.
- If a covered person moves out of the plan’s service area and loses access to care, a HIPAA SER applies
- Example
- A dependent covered under a California HMO moves to Nevada for school and loses access to in-network care → HIPAA SER applies.
- Employees and dependents may move to an employer plan that covers the new area or enroll in an individual plan on their state Exchange.
Important Clarification – Loss of ACA Subsidies
A loss or reduction of ACA Premium Tax Credits — including due to the expiration of enhanced subsidies — does not create a Special Enrollment Period to enroll in an employer-sponsored group health plan. A Special Enrollment Right applies only when a person loses coverage, not when the cost of an individual or Marketplace plan increases or becomes unaffordable.
COBRA Qualifying Events (Loss of Eligibility Events)
COBRA QEs apply only when the employee or dependent loses eligibility for the group health plan. These events trigger employer COBRA notices and continuation rights.
Common COBRA QEs include:
- Resignation or termination
- Reduction in hours causing loss of eligibility
- Dependent-only QEs (divorce, aging out, death, Medicare entitlement)
Refer to our COBRA Qualifying Events page for detailed rules, examples, and timelines.
Documentation & Timing Requirements
Accurate documentation and strict timing are essential for compliance.
Typical windows:
- HIPAA SERs: 30 days
- Medicaid/CHIP: 60 days
- Section 125 QEs: usually 30 days
- COBRA: strict federal notice and election timelines apply
These standards should be clearly outlined in the employer’s:
- ERISA plan documents
- Cafeteria plan documents
- HR/benefit policies